The temporomandibular joint (TMJ) is
a synovial joint formed by the condyle of the mandible, the
articular eminence of the temporal bone, and the articular disc that
is interposed between the two and divides each joint into two
cavities (1). When treating the TMJ, the plan of care should address
what is causing the problem to become manifest and the prevention of
further degeneration of the joint
(2). Numerous
physical therapy interventions are potentially effective in managing
temporomandibular disorders (TMD), including electrophysical
modalities, exercise, and manual therapy techniques
(3). Treatment of
other regions of the body such as the cervical spine/related
musculature, shoulder girdles, thoracic spine/related musculature,
lumbar spine and pelvis are also important as these areas may play a
postural component to the problem associated at the TMJ (4). When
treating patients with TMD, patients with an acute onset or post
traumatic injury are more likely to respond better to physical
therapy intervention while patients with a chronic TMD tend to not
respond as quickly
(3). This article will review some of the
treatment considerations for Temporomandibular Joint Disorders once a
thorough physical therapy evaluation has been completed and a
plan of care has been developed. (image from 20th U.S. edition
of Gray's Anatomy of the Human Body published in 1918)

Rocabado 6
x 6 Exercise Program (5)

This exercise program by Mariano
Rocabado addresses postural relationships with the head to neck,
neck to shoulders and lower jaw to upper jaw. The objective of this
home exercise program is for patients to: learn a new postural
position, fight the soft tissue memory of the old position, restore
the original muscle length-tension relationships, restore normal
joint mobility and restore normal body balance. Rocabado advocates
the instruction of six fundamental components of activity for
treatment of TMJ dysfunction. He recommends that patients complete
each activity 6x/session and 6x/day.

The activities are as follows:
1) Rest position of the tonguea) Make a clucking sound with the tongue x 6b) Find normal resting position = holding one third of tongue
gently against the roof of the mouth just behind the front teethc) Diaphragmatically breathe through nose while tongue is in
resting position x 6 breaths
2) Control TMJ Rotation on Opening – tongue on roof of mouth
and open x 6 reps
3) Mandibular Rhythmic Stabilization – apply light resistance
to opening, closing, and lateral deviation with the jaw in a resting
position holding for 6 seconds (this is key when a patient has
instability as this assists with visualization/neuromuscular
reeducation)
4) Stabilized Head Flexion = upper cervical flexion (nodding)
- facilitate upper cervical flexion as most of these patients have
forward head posture resulting in upper cervical extension
deviation. Nod head x 15 degrees back and forth 6 x reps.
5) Lower Cervical Retraction – chin tuck x 6 second hold
6) Shoulder Girdle Retraction – pull shoulders back and down
- hold x 6 seconds

Joint
Mobilization (2)

When the TMJ is restricted joint
mobilization can be performed in various directions to improve joint
play at the temporomandibular joint.

1) Isometric Contraction
with Jaw in Neutral – Open your jaw to neutral. Place your two thumbs under
your mandible (chin) and both your index fingers so that they are touching
your bottom teeth. You will then gradually apply resistance to your lower
teeth in the directions of lateral deviation, protrusion / retrusion or
opening / closing while maintaining the position of your mandible.

3) Isometric Cervical
Flexion in Forward Trunk Flexion – Sit forward in a chair with your
forehead supported by your forearm which is on a table. In this position,
bring your head forward about 15 degrees by flexing into your forearm while
maintaining your jaw in the resting position.

4) Resisted Lateral
Deviation Out of Neutral – From a neutral posture, laterally
deviate your jaw away from the involved side until your top and bottom canine
teeth match. In this position, use 1-2 fingers to provide resistance for
bringing your jaw back to a neutral position. "This helps to
stabilize the articular disc on the condylar head by strengthening its
lateral ligament attachments" (6).

1) Functional Jaw Opening – In
front of a mirror open and close your mouth to a comfortable
distance while attempting to prevent your jaw from deviating out of
a neutral position. In order to help with feedback, you can also
palpate the condylar head of your TMJ joint and tongue with your
index fingers. "Controlled opening facilitates joint mobility, good
circulation to the condylar head, cartilage conditioning, relaxation
of the pterygoid muscles, and neuromuscular control of a hypermobile
joint" (6).

2) Controlled-ROM Lateral Deviation –
In front of a mirror, with your jaw in a resting position, laterally
deviate your jaw until the canine tooth on the
lower jaw matches the canine tooth of the upper jaw. In order to
help with feedback you can also palpate the condylar
head with one index finger and the upper canine tooth with another
index finger to
cue movement limitations. "Controlled lateral deviation causes
distraction of the joint capsule, which can help attain ROM, improve
joint mobility and circulation, and control muscular spasm" (6).

3) Lateral Deviation + Functional Opening – In front of a
mirror, with jaw in a resting position, laterally deviate your jaw
followed by opening of your mouth. This movement causes
distraction of the joint capsule.

4) Protrusion ROM – In front of a mirror, with jaw in a
resting position, perform protrusion of your mandible by bringing it
forward followed by retrusion back to a resting
position.

5) Self-stretch into Opening –
Open your mouth in midline and provide a mild
overpressure to the top and bottom teeth at end-range. "Prolonged
stretching may also be recommended to increase opening ROM" (6).

6) Self-distraction Mobilizations – From a sitting
and resting position, rotate your head slightly to the opposite side of the involved
joint. Palpate the mandibular condyle with 1 finger while the
other thumb and fingers from the uninvolved side are placed on the mandible
towards the involved side. Distraction is provided by sidebending
your wrist inwards (ulnar deviation).

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